Clinician's Digest - Page 3

As the long-awaited next revision of the book known as the bible of mental health treatment lurches closer to publication, an undercurrent of criticism has exploded into a revolt by members of U.S. and British psychological and counseling organizations. The chief complaint is that the revision lowers diagnostic criteria, creates “subthreshold” disorders, and generally makes it easier to find a diagnosis that allows for the medication of patients.

The Diagnostic and Statistical Manual of Mental Disorders, better known as the DSM, is published by the American Psychiatric Association, and it’s used by virtually every U.S. mental health professional who wants reimbursement for services. It has a worldwide influence. The fifth edition is slated for publication in May 2013.

The latest reaction against the DSM-5 began with a salvo from across the Atlantic. A special committee of the British Psychological Society sent a letter in June complaining that “clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences.” The committee criticized the proposed creation of an “attenuated psychosis syndrome”—essentially a subthreshold form of psychosis that aims to identify young people who may develop schizophrenia—“as an opportunity to stigmatize eccentric people.” The committee objected to a proposed reduction in the number of symptoms needed to diagnose adolescents with attention deficit/hyperactivity disorder because it might increase diagnoses and the use of medication.

Then David Elkins, professor emeritus at Pepperdine University and president of the Society for Humanistic Psychology, division 32 of the American Psychological Association (APA), formed a committee to discuss similar objections, drafted a petition listing them, and posted the petition online. “I figured we’d get a couple hundred signatures,” Elkins remarks.

The response stunned him and his colleagues. Within three weeks of going online on 22 October, the petition had attracted more than 6,000 signatures and had been endorsed by 12 other divisions of the APA. On 8 November, American Counseling Association President Don Locke jumped in with a letter to the American Psychiatric Association objecting to the “incomplete or insufficient empirical evidence” underlying the proposed revisions and expressing “uncertainty about the quality and credibility” of the DSM-5.

“This has become a grassroots movement among mental health professionals, who are saying we already have a national problem with overmedication of children and the elderly, and we don’t want to exacerbate that,” notes Elkins.

David Kupfer, the University of Pittsburgh psychiatrist who chairs the task force overseeing the revision, says he welcomes the criticism, as nothing is final. “There’s a myth that all the decisions have been made, when in fact, all the decisions haven’t been made,” he says. “Just because [things have] been proposed doesn’t necessarily mean they’ll end up in the DSM-5.” He explains that the task force has been testing proposed new diagnoses in 2,300 patients at 11 field sites. “If they don’t achieve a level of reliability, clinician acceptability, and utility, it’s unlikely they’ll go forward,” he adds. Stay tuned. This battle isn’t going away.